Responding to widespread mental health problems in Zimbabwe, Professor Dixon Chibanda took to unusual methods – training a team of grandmothers in creating safe spaces for people to talk. ‘Friendship Bench’ is a result of their teamwork – organised around culturally embedded concepts surrounding wellbeing and belonging. In this interview, ‘Friendship Bench’ share with me the full story and meaning behind their project, and what message they ultimately wish to spread.
What is the story behind Friendship Bench? How did it first come to be?
In 2005 the Zimbabwean government launched a large-scale campaign called Operation Murambatsvina (“remove the filth”), also officially known as Operation Restore Order. The campaign was set to forcibly clear slums across the country. According to the United Nations it directly affected 700,000 people by leaving them homeless or taking away their livelihood and indirectly affected about 2.4 million people.
In 2006, Professor Dixon Chibanda, one of only eleven psychiatrists in Zimbabwe, and at the time the only one in the country working in the public health space were struggling to provide care to the 12 million strong population. Carrying out his fieldwork for a Master’s in public health, he found “extremely high” rates of common mental disorder (CMD) such as depression, anxiety and stress-related disorders as well as substance use disorders.
Chibanda approached his supervisors with his observations, but they told him that there were no resources they could give him as nurses were too busy with HIV-related issues and maternal and child health care, and clinics operated at full capacity already. Chibanda grew increasingly frustrated with the health system, this frustration turned to grief when one of his patients, Erica, took her own life.
Chibanda recalls, “One day Erica’s mother called to tell me that her daughter had hanged herself from a mango tree. When I asked why they hadn’t come to see me for review, her response was: ‘We couldn’t come because I didn’t have the bus fare’.” They did not have the $10 needed to come to Harare to see him.
While brainstorming how to tackle this problem, Chibanda arrived at an unlikely solution. What he says about it is; “A lot of people think I’m a genius for thinking of this, but it’s not true, I just had to work with what was there.” And there were 14 grandmothers and access to a space outside the clinic building.
Lacking any other option, Chibanda and his mental health colleagues began training the grandmothers. At first, he tried to adhere to the medical terminology developed in the West, using words like “depression” and “suicidal ideation”. But the grandmothers told him this wouldn’t work. In order to reach people, they insisted, they needed to communicate through culturally rooted concepts that people can identify with. So in addition to the formal training they worked together to incorporate Shona concepts of opening up the mind, and uplifting and strengthening the spirit.
How would you describe the state of mental health in Zimbabwe?
In Zimbabwe there are 6 in-patient psychiatric facilities, in-patients typically present with schizophrenia, substance-induced psychosis, bipolar affective disorder (mania), epilepsy or the psychiatric complications of HIV. In the psychiatric out-patient clinics and private practice, depression, substance dependency and anxiety disorders are also typical.
Mental health has never been high on the priority list in Zimbabwe, matters such as drought, food shortages and the HIV/AIDS epidemic have been more urgent.
Substance abuse starts at a very young age, it is common to see street children sniffing glue at traffic lights and for youth to smoke marijuana, many then report moving onto stronger substances such as crystal meth and the so psychosis as the result of a substance abuse is what largely presents in psychiatric facilities.
Musombodia, the street name for an illicit alcohol brew composed of diluted ethanol or methanol then mixed with juice is everywhere and no-where; the clear liquid is often sold in standard water bottles, it is colourless and odourless. It’s alleged to contain 95% alcohol and so can be consumed in very small quantities to result in hours of drunkenness; a time they “stick”, meaning the person will not be able to move their body parts and resemble a zombie as the alcohol stiffens their body. With a population where 48% of people are under the age of 18, and the start of substance misuse is in the younger generations the ongoing ripples effects are great (homelessness, domestic violence, theft, suicide, risk taking behaviour such as unprotected sex, drug-induced depression).
Due to the unemployment rate in Zimbabwe, hyperinflation, food shortages, now covid-19 restrictions it means the level of poverty is rapidly increasing. A 2017 report by ZimStat pointed out that 71% (over 10 million) of the Zimbabwean population lived in poverty. Poverty is one of the most significant social determinants of health and mental health and it spans generations. The lack of access to affordable care, low levels of education, inability to afford medication, dilapidated health care system and underpaid staff in the facilities, means that mental health problems go greatly undertreated and undiagnosed.
What have you noticed about the general perceptions of mental health amongst people in Zimbabwe?
Stigma and discrimination of people with mental health conditions is rampant in Zimbabwe. People lack information on mental health and mental ill health which means there are great misconceptions about mental illness. Some people associate mental illness with traditional harmful practices or evil spirits, others blame the person for the illness; people say that if you have a mental illness it’s because you’ve committed a crime against somebody or disrespected your ancestors and so the illness is punishment for that, it can also be because someone hasn’t prayed enough or followed the teachings of the Church so it’s a punishment sent from God.
All this means that when people suffer from a mental illness their relatives often take them to traditional healers before they think of going to hospitals or clinics. Some people with a mental illness get rejected by their relatives, some families cannot cope and so they ‘dump’ the person at a psychiatric facility and never go back to visit or check on how they are doing. There is little to no social support.
What different reactions have you received from others in response to your projects?
Chibanda; “Before the trial a lot of people thought it was a ridiculous idea, my colleagues told me, ‘This is nonsense.’”
We had a lot of interest from other organizations who work in the field of psychosocial support and who were curious about us working on a proof of concept before pursuing a the development of a scale up strategy. We feel it is crucial to push for evidence-based interventions and encourage everyone to engage in doing research, especially implementation research during roll out of programs.
What does the Friendship Bench mean or symbolise to you?
Besides bringing an evidence-based intervention to people, FB enables the discussion about mental health to start on a broader level. This is needed for people to receive the kind of knowledge that helps break stigma which still hinders way too many from seeking help.
“Creating a safe space and a sense of belonging” seem to be really important part of your groups. Why do you feel it’s important to emphasise these for your groups in particular?
Human beings are social beings. They need meaningful and trusted social connection to thrive, when these are or become unavailable, people experience higher level of stress. Anxiety and depression can lead to people perceiving themselves as inadequate and unworthy. A typical characteristic of anxiety is avoidance and of depression social withdrawal. Both these maladaptative coping mechanisms give a short term relief and yet exacerbate the issues.
We believe in a safe space where people can learn to work and reduce with their anxiety or depression symptoms by learning to reconnect with and trust a non-judgemental person and ultimately with themselves. With learning to tackle a self-chosen problem, people can re-experience themselves as agents of their lives and becoming part of the peer-led group support, they will be socially reconnect and give support to others as well which can be very meaningful.
We also believe that people who are empowered through Friendship Bench can take the learnings back to their families and communities and contribute to (mentally) healthier environments.
What does empathy mean to you?
In Friendship Bench, we want people to engage with each other on the emotional human level. Empathy means that the FB counsellor is not scared of the emotions a person brings in and much rather helps the person to visit the emotions and give a space to them. Somehow, our society has developed a bias towards positive emotions as the only ones that are acceptable.
We believe that all emotional experience is natural and human. With this understanding, we are teaching emotional regulation in both client and counsellor to increase distress tolerance. Judging emotions is part of self-stigma and hinders people from seeking help (as well as fearing being judged by other of course). Mental health issues which are treated early will be less likely to worsen and possibly become chronic.
Which are the greatest challenges you have faced with this project?
Terminology was a barrier in the beginning, medical terms such as ‘depression’ or ‘suicide ideation’ created in the West wouldn’t fit here. We had to develop culturally rooted concepts that people could identify with, hence we talk about ‘kufungisisa’ which directly translates into ‘thinking too much’ and is symptomatic of a combination of anxiety and depression in Western terms.
Stigma was also a challenge, at first the bench was called the ‘mental health bench’ but no one came to see the Grandmothers to talk until the name changed. People didn’t want to be associated with anything that had the word ‘mental’ near it because the limit of understanding is that it meant crazy, you were bewitched or were being punished by God for something you had done. You would be cast out in the community and stigmatised for angering the ancestors, and you would bring shame to your entire family.
To me, what you do seems like a form of group therapy. Is that how you perceive it?
There is a group therapy component to the Friendship Bench intervention, so you are quite right there.
After the one-on-one talk therapy, Friendship Bench clients are introduced to a peer led support group known as Circle Kubatana Tose (CKT), meaning ‘holding hands together’. In these groups clients are connected to others who have sat on the Friendship Bench, received PST and became empowered to solve their own problems. Group members can relate to one another because they tend to come from the same community and have learned about the benefit of empathic listening. This safe space to talk in and be heard contributes to clients’ sense of belonging and reduces stigma surrounding mental health and sharing of personal issues.
In the CKT groups, clients are engaged in revenue generating opportunities, learning to crochet items out of recycled plastic bags and old VHS tape ribbon! Some items commonly made and then sold in the community are bags, hats and mats. So beyond the group being a form of ongoing support and behavioural activation, it becomes a vital part of the intervention due to the need for income generation in a country going through socio-economic distress.
How would you describe the atmosphere in these groups?
These groups are full of life, love and energy. As stories are exchanged there is growing peace and hope amongst its members, individuals realise they are no longer alone, they are not mad or crazy, they have found people who understand them, listen to them and will message them to check up if for some reason they miss the group.
There is a strength amongst the women when they are together crocheting bags, empowered by their newly found ability to create an income and therefore be able to look after their children; having an income is a life line and hugely reduces the symptoms of anxiety and depression.
What message do you ultimately want to spread?
Ultimately we want to spread the message that with empathy, connection and the creation of safe places where people can talk and find a sense of belonging, the healthier happier and more harmonious we can all be in the world.
What does empathy mean to you?